CLIENT INTAKE FORM

New Client Form

Please provide you details below
FULL NAME
GENDER
D.O.B
PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
ADDRESS
CITY
POST CODE
Would you like to receive a copy of our occasional newsletter to the address you have provided?
EMERGENCY CONTACT NAME
PHONE
Format: (000) 000-0000.
RELATIONSHIP TO YOU
Are you currently seeing a natural health practitioner? (naturopath, etc.)
Current Practitoners Name:
Current Practitioners Contact Number:
Are you currently seeing a doctor?
Current GP's Name:
Current GP's Contact Number:
Please provide as much information as you are comfortable with in the following section as it will help me be more thorough:
Are you a smoker?

Other
Are you Drug or Alcohol Dependent?

Other
If yes, can you please tell me more about them?
Do you have Mental Health Issues?

Other
If yes, can you please tell me more about them?
Do you have Chronic Pain?

Other
If you have Chronic Pain, can you please describe where it is located and more about it?
Do you have Respiratory Issues ?

Other
If yes, can you please tell me more about them?
Do you have Cardiovascular Issues, Heart Issues, or Circulation Issues,?

Other
If yes to any, can you please tell me more about them?
Do you have a Neurological Issues or Diagnosis?

Other
If yes, can you please list them?
Do you have Musculoskeletal Issues? (e.g. arthritis, joint problems, back pain, fractures, etc.)

Other
If yes, can you please tell me more about them?
Do you have Gastrointestinal Issues? (e.g. digestive issues, bowel problems, etc.)

Other
If yes, can you please tell me more about them?
Do you have Urinary Issues, Reproductive Issues, or Prostate Issues?

Other
If yes to any, can you please tell me more about them? :
Do you have Diabetes, or Cancer?

Other
Do you have any allergies or sensitivities? Describe here:
Do you have any other current medical diagnosis not covered in the above? Please describe, if yes.
What are the current prescription medications and/or vitamin supplements you are taking? Please list all.
Please select the therapies you are requesting

Other
Have you had any of these therapies before?
Are you pregnant?
Do you plan to become pregnant in the future?
If yes, how soon in the future?
What are your Therapy Goals? What are you looking to achieve in the session with me?
How did you hear about my offerings & services? Who referred you to me?
How would you describe your general state of health & well-being?
INFORMED CONSENT

I understand that the therapy provided by Jo Anastasio of Melbourne Hyperbaric Oxygen Therapies is only for the purpose of stress reduction, relief from muscular tension or spasm, for facilitation of circulation, energy flow or relief from stiff joints. I understand that the therapist is not qualified to diagnose illness, disease or any other physical or mental disorder. I take it upon myself to update my therapist regarding any changes in my condition. I hereby consent to engaging in remote services and receiving these services in the forms stated.
BY SIGNING BELOW, I DECLARE THAT:
All answers and information provided on this form are true, correct and complete. I have stated all my known medical and physical conditions, past and present, and acknowledge my responsibility to inform the practitioner before any future sessions commences of any changes to my medical, or physical status. I have been fully informed about the nature of the treatment to be provided. I have had the opportunity to ask questions, and have had my questions answered to my satisfaction.

I consent to the initial and ongoing consultations with the practitioner. I agree that this consent form will remain ACTIVE for future visits unless I otherwise notify the practitioner in writing
SIGNATURE
DATE:
Please verify that you are human
Can you please tell me more about this?
Should be Empty:

New Client Form

Please provide as much information as you are comfortable with in the following section as it will help me be more thorough:

INFORMED CONSENT

BY SIGNING BELOW, I DECLARE THAT: